Nearly 20% of all people infected with HIV in the US pass through a correctional facility each year. Several studies suggest that the prevalence of HIV infection among prisoners is between 8 and 10-fold higher than the prevalence in non-incarcerated populations and a significant proportion of inmates are at elevated risk for infection. Voluntary counseling and testing (VCT) of individuals at risk for HIV infection is an effective means of primary and secondary HIV prevention. The North Carolina Department of Corrections (NCDOC) has a voluntary HIV testing policy and 70% of all incoming inmates decline the opportunity to receive testing. As is the case for the other 31 state prison systems that employ voluntary testing, this is a lost opportunity to identify infected people and enroll them in care. Unfortunately, we are missing several pieces of information required both to determine the true prevalence of HIV infection among incarcerated people as well as to understand how newly incarcerated people make the decision to receive an HIV test. In a collaborative effort between researchers at the UNC Schools of Medicine and Public Health and officials at the NCDOC and the North Carolina Department of Health and Human Services (NCDHHS), we will perform a comprehensive assessment of the barriers and facilitators of HIV testing in a large state prison system. First, we will determine the actual prevalence of acute and chronic HIV infection among incoming inmates and characterize the HIV risk behaviors of this group. Second, we will examine the association between the uptake of voluntary HIV testing among recently incarcerated inmates and variables at three levels: individual inmate, NCDOC nurse-counselor and prison processing facility. Finally, we will conduct a preliminary examination of the risks associated with receiving an HIV diagnosis in prison. The ultimate goals of the studies described in this application are to obtain a clearer picture of the impact of HIV infection among this population and to inform the design of interventions to promote HIV VCT in this setting. Specifically, we will: Aim 1. Determine the prevalence of acute and chronic HIV infection in a large state prison system. Aim 2. Determine the inmate, nurse-counselor and facility characteristics associated with agreeing to HIV VCT. Aim 3. Explore the risks associated with receiving an HIV diagnosis in prison.